Components of the FPD

FIXED PARTIAL DENTURES

Treatment Planning and Biomechanics
Donna N. Deines, DDS, MS Resources: Shillingburg, et al Rosenstiel, et al

Abutment: tooth serving as attachment for FPD Retainer: extracoronal restoration cemented to abutment Pontic: artificial tooth suspended from abutments Connector: rigid or non-rigid metal connecting pontics / retainers

Treatment of Tooth Loss

Consequences of tooth loss:

Caries Periodontitis Trauma, congenital

Decision to remove tooth Careful assessment Replacement decision

Supra-eruption Tilting Loss of proximal contact Disruption of occlusion

Restoration of the Occlusal Plane

Relation of Tooth Loss to the Edentulous Ridge

Occlusal interferences are produced when FPD is made to a supraerupted opposing dentition. Opposing tooth restored to correct occlusal plane May require RCT; periodontal surgery; orthodontics; extraction

Alveolar ridge resorption results vary due to individual patient factors length of time, existence of periodontal disease, trauma, arch, etc.

Relation of Tooth Loss to the Edentulous Ridge

Indications for a Fixed Partial Denture

Knife-edge ridge Loss of interdental papillae

Replace function of missing teeth Stabilize occlusion (drifting, prematurities) Improve stress distribution Provide esthetics and phonetics Comfort

Contraindications for FPD

Too great a span length Long edentulous space at the end of an arch Tipped abutments, divergent alignment Non-restorable abutment teeth or periodontium Severe loss of tissue in the edentulous ridge (Limited financial ability / advanced age or systemic (terminal) illnesses)

Stress Distribution in Fixed Partial Dentures

An FPD distributes forces favorably by directing forces in the long axis of the abutment teeth.

Conventional Fixed Partial Denture

Resin-Bonded Fixed Partial Denture

Abutment on each end Periodontally sound abutments, straight alignment No gross soft tissue defect Dry mouth increases risk of failure

Conservative, enamel preparation Single missing tooth; slight - moderate tissue resorption Good axial alignment and light occlusal stresses Especially indicated for younger patients

Posterior Resin-Bonded FPD

Implant-Supported Crown / Fixed Partial Denture

Occlusal rests; 180o encirclement of axial tooth structure. Single molar replacement requires minimum occlusal load.

Indications: insufficient abutments / no distal abutment Single tooth implant saves virgin adjacent teeth Span length limited by availability of bone / ridge configuration

Implant-Supported Fixed Partial Dentures

Limitations of Implant Placement

Prosthesis is usually not attached to adjoining natural teeth. Implant-supported fixed prosthesis placed in a totally edentulous mandible

Amount of bone may severely limit potential for implant placement - maxillary sinus / mandibular canal Precise abutment alignment and positioning for occlusal forces

Implant-Supported Fixed Partial Dentures

Indications for Removable Partial Dentures

Insufficient number of abutment teeth Lack of distal abutment Connection of implants / natural teeth can be compromised

Periodontally involved teeth Tilted molar abutments Multiple edentulous spaces Edentulous space with no distal abutment

Treatment Options for Tooth Loss

Gross soft tissue defects

Removable Partial Denture (RPD)

Traumatic injury Ablative surgery

Disadvantages of Removable Prostheses

Soft tissue irritation of edentulous ridge Less comfortable than FPD Esthetics often inferior to FPD

Fixed partial dentures are preferred for comfort and esthetics

Case Presentation
Present treatment options
Advantages / disadvantages Patient input esthetics, finances

Agree on definitive treatment plan

Understanding of risks / responsibilities No prosthetic treatment
Unrealistic expectations Do no harm

Abutment Evaluation
Caries Existing restorations Endodontic assessment Periodontal health Orthodontic position Occlusion

Abutment Evaluation: Remove all caries, old restorations, base; then evaluate.

Pulp exposure? Symptomatic? PA pathology? Proximity of cavity depth to alveolar crest Biologic width

Pulpal Health: Vital or Endodontically Treated Asymptomatic with sound tooth structure remaining. Questionable / pulpal exposure RCT before FPD

Evaluation of Diagnostic Casts:

Accurate
Mounted on semi-adjustable articulator w/ facebow / CR Edentulous spaces and span length Curvature of the arch Occlusocervical dimension Inclination of the abutment teeth M-D drifting, rotation, F-L displacement of abutments Interocclusal relationships

Abutment Alignment and Path of Insertion

Evaluation of the path of insertion

Discrepancies in the long axes of abutment teeth

Evaluation of Interocclusal Relations

Complicates the ability to prepare parallel paths of insertion. Facio-lingual and mesio-distal inclinations

Interocclusal space is necessary to re-establish a proper occlusal plane. The occlusion may be acceptable or changes may necessary.

Diagnostic waxing: visualize problems and results

Diagnostic Waxing and Case Planning

OR

Healthy periodontium: a prerequisite for all fixed prosthodontic restorations

Abutment Evaluation: Crown-Root Ratio

No mobility / zone of attached tissue / good oral hygiene Additional abutment evaluation of the periodontium: Crown-root ratio Root configuration Periodontal ligament area

Crown - Root Ratio Length of tooth occlusal to the alveolar crest compared with the length of root embedded in bone Optimum C:R is 2:3 Minimum C:R is 1:1

Periodontal disease - Horizontal bone loss dramatically reduces supported root surface area

A crown-root ratio 1:1 may be adequate if:

Opposing occlusal force is diminished

Artificial teeth
Periodontally compromised
Rosenstiel

Conical root shape diminishes actual area of support more than expected from the height of bone. The center of rotation (R) moves apically and the lever arm (L) increases, magnifying the forces on the supportive structure.

Abutment Evaluation: Root Configuration

Favorable: elliptical; widely separated roots; curvature in apical 1/3 Unfavorable: round; fused roots; conical taper Well aligned tooth provides better support than a tilted one.

Root Morphology

2nd molar long, separated roots; 1st molar extensive caries and positioned against adjacent tooth.

Abutment Evaluation: Root Surface (Periodontal Ligament) Area

Generally successful

Antes Law: The root surface area of the abutment teeth (embedded in bone) should equal or surpass that of the teeth being replaced with pontics.

Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.

Probably, but limit is being approached

Generally unacceptable
Any FPD replacing more than 2 posterior teeth - risky

Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.

Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.

Anterior FPD replacing incisors

Antes Law A guideline with validity

Most common FPD to replace more than two teeth with success

Long span FPDs fail due to abnormal stress attributed to: Leverage and torque Material failure

Antes Law A guideline with validity (More than just overloading the PDL) Long span FPDs fail due to abnormal stress which is attributed to:
1) Leverage and torque 2) Material failure

Biomechanical Problems: Bending or Deflection of the FPD

Fracture of porcelain veneer Connector breakage Retainer loosening and caries Unfavorable tooth or tissue response.

Deflection of the FPD relates to span length

The deflection is proportional (varies directly) to the cube of the length of its span.

Law of Beams

Bending also varies inversely with the cube of the occlusogingival thickness of the pontic / connector
Design pontic/connector with adequate O-G thickness Use alloy with high yield strength

BIOMECHANICAL CONSIDERATIONS

Dislodging forces on an FPD

Bending or deflection of the FPD

Abutments and retainers receive greater torque than a single crown Modify preparations to increase retention and resistance
Place boxes / grooves in response to direction of anticipated torque Occlusal forces can act in a M-D direction on an FPD. Forces at an oblique angle or outside the center of the restoration cause F-L dislodgement .

FPD and Dislodging Forces

Double abutments (splinting) can help problems caused by poor crown-root ratio and long spans.

Grooves / boxes 8resistance to dislodgement. Place boxes / grooves in response to direction of anticipated torque. Use retainer with appropriate retention / resistance.

Double abutments help stabilize the prosthesis by distributing forces over more teeth.

Criteria for secondary abutments:

Long-term periodontal splint

Root surface area and C:R must = 1o abutments 2o retainers must have retention of 1o retainers Long crown length and adequate interproximal space for connectors

Bone loss and increased physiologic movement Deflection / torque microleakage / debonding Caries involvement of abutment teeth Fracture of RCT abutment with large amount of missing tooth structure

Is splinting necessary here?

Effect of Arch Curvature on FPD Deflection

Pontics lying outside the inter-abutment axis act as a lever arm torquing movement. Additional resistance in opposite direction from lever arm; distance = to length of the lever arm

SPECIAL PROBLEMS: Pier Abutments

SPECIAL PROBLEMS: Pier Abutments Cause of failure - loosened retainer

Prosthesis flexure / movement of teeth Tensile stresses between terminal retainers and abutments; intrusion of abutments under loading Differences in retentive capacities between abutments (relative to size)

An edentulous space on both sides of a lone freestanding abutment Physiologic tooth movement
direction and amount varies from anterior to posterior

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FPD #4-6-8 (Pier abutment #6) Rigid Connectors

Extensive caries through crown resulting from #6 retainer debonding from abutment.

Non-Rigid Connector

Non-Rigid Connector / Pier Abutment

Criteria for use:

Short span length Non-mobile abutments Equal distribution of occlusal force

Location:

Within distal surface of pier retainer (mesial seating action of posteriors)

Non-rigid connector (stress breaker)

Special Problem: Pier Abutment

Where periodontal support is adequate, a simpler approach could be a mesial cantilever pontic.

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Implant supported FPD #5-#6-#7

SPECIAL PROBLEMS: Tilted Molar Abutment

Discrepancy between long axis of molar and premolar abutments 25o - 30o - maximum angle of tilting

SPECIAL PROBLEMS: Tilted Molar Abutment

SPECIAL PROBLEMS: Tilted Molar Abutment

Mesial wall must be over-reduced ( resistance) Distal adjacent tooth may intrude on the path of insertion

Plan path of insertion / preparation design on diagnostic cast. Surveyor may help in determination

SPECIAL PROBLEMS: Tilted Molar Abutment

SPECIAL PROBLEMS: Tilted Molar Abutment

Occlusal reduction is not always the same as clearance needed. Remove only enough to provide necessary space for the restoration. Allows for longer axial wall length.

Molar uprighting
Places abutment in better position for preparation Distributes forces under loading through long axis of tooth (helps eliminate mesial bony defects) Enables replacement of optimum occlusion

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Tilted Molar Abutments: Proximal Half Crown

Orthodontic Movement: Molar Uprighting

Proximal Half Crown does not involve distal wall A 3/4 crown rotated 90o Requirements: Caries-free distal surface Low incidence of caries Even marginal ridge height

Tilted Molar Abutments:

Telescopic Coping and Crown

Full crown preparation and coping with path of insertion in long axis of tooth Full coverage crown compensates for discrepancy in paths of insertion Must over-reduce molar to accommodate the thickness of coping and crown

Proximal Half Crown Retainer

Tilted Molar Abutments: Non-Rigid Connector

Canine Replacement FPD (Complex)

Allows slight movement - short span Keyway in distal of premolar to avoid intrusion of molar (mesial seating action) Must prepare box in distal of premolar preparation

Pontic lies outside the inter-abutment axis Stress is greater on maxillary arch
Forces inside arch (weak - tension)

Stress more favorable in mandibular arch

Forces outside arch (strong compression)

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Anterior Fixed Partial Dentures (replacing four incisors)

Canine Replacement FPD

Forces outside inter-abutment axis (esp. maxillary) Generally longer lever arm with more pronounced curve on maxillary Forces against maxillary are directed unfavorably (outward) Forces against mandibular are directed favorably (inward)

Pontic lies outside the inter-abutment axis Adjacent teeth are weakest possible abutments Should not replace more than one additional tooth Canine plus 2 contiguous teeth poor prognosis
restore with RPD or implants

SPECIAL PROBLEMS: Cantilever FPD

(Potentially destructive lever arm)

Cantilever FPD: Replacement of maxillary lateral incisor

Replace only 1 tooth, and have at least 2 abutments Criteria for abutment teeth:
Long root w/ good configuration Long clinical crown Favorable crown:root ratio and healthy periodontium Only the canine should be used as a solo abutment
Rest should be placed on mesial of pontic against a rest prep in a restoration in the distal of the central incisor

Unfavorable occlusion: deep vertical overlap

Unfavorable Central Incisor Cantilever Pontic FPD

Unfavorable Cantilever: Lateral incisor abutment Severe vertical overlap

Solution: 1) Conventional FPD #8-#10 2) Single implant retained crown

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Resin-bonded hybrid cantilever

Full crown retainer central incisor #9 Resin-bonded wing / mesial preparation #7 Favorable occlusion

Cantilever FPD:

Replacement of First Premolar

Cantilever: First Premolar Resin-bonded retainer on canine (mesial rest)

Limit pontic occlusion to distal fossa. Use full veneer retainers on the 2nd premolar and 1st molar.

When using a rest on a cantilever pontic, always place a rest prep in a restoration on the abutment.

Missing tooth less than space

Caries
Change proximal contour / occlusion Button pontic Importance of resistance form: clinical crown length; facial lingual grooves; minimal taper

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Cantilever FPD: Molar Replacement Very Unfavorable

Cantilever FPD: Replacement of First Molar

Unfavorable
Pontic size small (premolar) Light occlusal contact; no excursive contact Pontic and connector Maximum O-G height for rigidity Good crown:root ratio of abutments Clinical crowns - maximum preparation length and resistance form

Extreme forces generated by posterior position (Class 2 lever) Occlusal forces place tensile stress on 2o retainer

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